Acute severe asthma in pediatrics

1. ACUTE SEVERE ASTHMA (STATUS ASTHMATICUS)
MODERATOR
DR. RAKESH RANJAN
ASSISTANT PROFESSOR PEDIATRIC
DEPARTMENT
SHRI KRISHNA MEDICAL
COLLEGE,MUZZAFARPUR
PRESENTER
DR. JAIKISHAN
PG- DNB(2nd YEAR)
PEDIATRIC DEPARTMENT
SKMC, MUZZAFARPUR

3. DEFINITION OF ASTHMA
• It is a chronic inflammatory condition of the
lung airway resulting in episodic airflow
obstruction. This chronic inflammation
heightens the twitchiness of the
- airways hyperresponsiveness (AHR) - to
common provocative exposure

4. ETIOLOGY

5. PATHOPHYSIOLOGY
Airway inflammation & hyper-
reactivity
Smooth muscle spasm
Mucosal edema & plugging

6. CLINICAL MANIFESTATION
• Intermittent dry coughing and EXPIRATORY WHEEZING.
• Shortness of breath and chest congestion and tightness.
• Respiratory symptoms worse at night, especially during prolonged
exacerbation triggered by RESPIRATORY INFECTIONS or INHALANT
ALLERGENS (pollens, malts, dust mites, animal dander).
• Day time symptoms are often linked with physical activities (exercise
or play induced)
• Asthma symptoms can be triggered by numerous common events or
exposure – Physical exertion and hyper ventilation, cold or dry air,
and airway irritants.
• Common respiratory pathogens – Rhinovirus, RSV, Influenza and
parainfluenza, myco plasma pneumonia has induced airway
inflammation.

7. Initial treatment of Asthma

8. GINA 2020

9. 1. Remove cap and shake inhaler in
vertical direction
2. Breathe out gently
3. Put mouth piece in mouth. At start
of inspiration that should be slow
and deep, press canister down
and continue to inhale deeply.
4. Hold breath for 10 seconds or as
long as possible then breathe out
slowly.
5. Wait for a few seconds before
repeating steps 2-4.
A) METERED DOSE INHALER
B) METERED DOSE INHALER WITH SPACER
1. Remove cap, shake inhaler and insert into
spacer device
2. Place mouth piece of spacer in mouth.
3. Start breathing in and out gently and
observe movement of valve.
4. Once breathing pattern is established press
canister and continue to breathe 5 -10 times
(Tidal Breathing)
5. Remove the device from mouth and wait for
30 seconds before repeating steps 1-4.

10. C) METERED DOSE INHALER WITH
SPACER AND FACEMASK
1. Attach baby mask to the mouth end of
spacer
2. Shake MDI; insert it in the MDI end of
spacer device.
3. Cover baby’s mouth and nose with baby
mask
4. Press canister and encourage the child to
take tidal breathing with mouth open (if
possible) 5-10 times.
5. Remove baby mask and wait for 30-60
seconds before repeating step 1-4.
D) ROTAHALER
1. Hold rotahaler vertically and insert
capsule (clear end first) into square
hole, make sure that the capsule is
level with top of hole
2. Hold rotahaler horizontally, twist
barrel in clockwise and anti-clockwise
directions, this will split the capsule
into two.
3. Breath out gently, put mouth end of
rotahaler in mouth and take deep
inspiration.
4. Remove rotahaler from mouth, hold
breath for 10 seconds.

11. E) NEBULIZER
1. Connect output of compressor to
nebulizer chamber by the tubing provided
with the nebulizer.
2. Put measured amount of drug in nebulizer
chamber, add normal saline to make the
total volume 2.5 – 3 ml
3. Switch on the compressor and look for
aerosol coming out form the nebulizer
chamber.
4. Attach facemask to the nebulizer
chamber, ensure appropriate fit to cover
nose and mouth to the child.
5. Encourage child to take tidal breathing to
open mouth.
Children < 4-year old: MDI with spacer
with facemask
Children > 4-year old: MDI with spacer
preferred
Children > 12 year old: MDI used
directly. Use of spacer improves drug
deposition.

12. Definition of Status Asthmaticus
• A severe exacerbation of asthma that does not
improve with standard therapy is termed as
status asthmaticus.
• Clinical Definition - Severe asthma that failsto
respond to inhaled β2 agonists, oral or IV steroids, and
O2, and that requires admission to the hospital for
treatment

13. Pathophysiology ofstatus
asthmaticus
Pathologic changes in the airway  airflow
obstruction  premature airway closure on
expiration  dynamic hyperinflation 
hypercarbia
Dynamic hyperinflation or “air-trapping” also
leads to ventilation / perfusion (V/Q) mismatching
causing hypoxemia

14. Presentation
Varies by severity, asthmatic trigger, and patient
age.
▶ Cough
▶ Wheezing
▶ Increased work of breathing.
▶ The noisy chest
The degree of wheezing does not correlate well with
severity of the disease.

15. Assessment
Primary assessment
▶ Airway
▶ Breathing
▶ Circulation
▶ Disability
▶ Exposure
Secondary assessment (Focused history and
examination)

16. Prognosis
High risk factors for asthma severity and fatality
▶ Previous severe sudden deterioration,
▶ Past PICU admissions
▶ Previous respiratory failure
▶ Need formechanical ventilation.

17. Presentation ‘Red-alerts’
Severe respiratory compromise:
▶ ‘Silent Chest’ with increased respiratory efforts usually
precede respiratory failure.
▶ Agitation or dyspnea
▶ Altered consciousness
▶ Inability to speak >1-2 words at a time
▶ Central cyanosis
▶ Diaphoresis
▶ Inability to lie down
▶ Pulsusparadoxus >
25 mmHg
▶ PaCO2 normalization or hypercapnia (ominous)
▶ Bradycardia
▶ Severe Hypoxia

18. Assessmentof severity
BeckerAsthma score
The assessment of severity of acute severe asthma is based on clinical
observation of the child. Becker Asthma score is a quick assessment of
severity, by using respiratory rate, wheezing, inspiratory, expiratory ratio
and accessory muscles use.

19. Oxygen Therapy
▶ 100% oxygen
▶ Oxygen saturation monitoring
▶ Other monitors

20. Pulsus Paradoxus

21. Cardiopulmonary Interactions
▶ Severe the attack, more negative intrapleural
pressure
▶ Increased left ventricular afterload
▶ Increased transcapillary filtration of edema fluid
into airspaces resulting in a high risk for pulmonary
edema.
▶ Overhydration increasesmicrovascular
hydrostatic pressure and furtherworsens
pulmonary edema.
▶ High right ventricularafter load due to
▶ Hypoxic pulmonary vasoconstriction,
▶ Acidosis
▶ Increased lung volume.

22. Chest Radiography
Limited role but indicated in-
▶ First time wheezers
▶ Clinical evidence of parenchymal disease
▶ Those requiring admission to PICU.
▶ Suspected airleak orpneumonia
▶ When the underlying cause of wheezing is in
doubt

23. Arterial blood gas
▶ In all children at baseline
▶ Subsequently as indicated
▶ Hypocarbia in early stage
▶ Normalization of CO2 with persistent respiratory
distress indicates impending respiratory failure.
▶ A PaO2<60 mm Hg and a normal or increased
PaCO2 (>45 mm Hg) indicates the presence of
respiratory failure

24. PICUAdmission
▶ Comfortable environment
▶ IV access
▶ Maintain euvolemia
▶ Continuous cardio-respiratory monitoring
▶ Avoid sedation
▶ Monitorpotassium
▶ Antibiotics, if indicated
▶ If ventilated -arterial and central venous access

25. Fluid
▶ Restoration of euvolemia
▶ Isotonic fluid like normal saline or Ringer’s lactate
▶ Fluid balance
▶ Avoid overhydration;Riskof pulm edema
▶ Serum potassium monitoring

26. Antibiotics
▶ Not routinely indicated
▶ Reserved forchildren with evidence of bacterial
infection
▶ High fever
▶ Consolidation on X ray film or
▶ Very high leucocyte counts

27. Pharmacologic Targets
▶ Improving oxygen delivery
▶ Relaxation of bronchial smooth muscles
▶ B2 receptors
▶ M1 receptors
▶ Attenuating underlying inflammation

28. M
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29. M
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30. MANAGEMENT PROTOCOL

32. Adverse effectsof β2-
agonists
▶ Cardiovascularsystem
▶ Tachycardia
▶ Increased QTc interval
▶ Dysarrhythmia
▶ Hypertension
▶ Diastolic hypotension.
▶ Excessive CNSstimulation
▶ Hyperactivity,
▶ Tremors
▶ Nausea with vomiting
▶ Hypokalemia
▶ Hyperglycemia

33. Corticosteroids: Side
effects
▶ Short-term use of high-dose steroids
▶ Hyperglycemia
▶ Hypertension
▶ Acute psychosis
▶ Prolonged steroid
▶ Immunosuppression
▶ Hypothalamic-pituitary-adrenal axis suppression,
▶ Osteoporosis
▶ Myopathy
▶ Weakness

34. Magnesium Sulfate
▶ Mechanism:
▶ InhibitsCa2+ influxintocytosol smooth muscle relaxant
▶IncreasesB2agonist affinity for itsreceptor, thereby potentiating itseffect
▶ Inhibitshistaminerelease frommastcells
▶ 50mg/kg IV over20-30minwithmax of 2gm
▶ Repeat once ortwice after4–6h.
SIDEEFFECTS
▶ Hypotension
▶ CNSdepression,
▶ Muscle weakness
▶ Flushing
▶ Cardiac arrhythmia/ complete heartblock,
▶ Respiratoryfailuredue to severe muscle weakness

35. Mechanical Ventilation
Indications
▶ Poorresponse to initial therapy
▶ Severe hypoxia
▶ Rapid deterioration in mental state
▶ Rising PCO2
▶ Cardiopulmonary arrest

36. Intubation Tips
▶ Preoxygenate with 100%oxygen
▶ Anticipate hypotension
▶ Cuffed ETtube with the largest appropriate
diameter
▶ Avoid histamine-producing agents like morphine
or atracurium
▶ Ketamine: preferred induction agent due to its
bronchodilatory action.
▶ Use atropine, Benzodiazepam and by a rapid-
acting muscle relaxant (vecuronium).

37. Complications
▶ Hypotension
▶ Oxygen desaturation
▶ Pneumothorax/ subcutaneousemphysema,
▶ Cardiac arrest
▶ Suspect tension pneumothorax and treat
promptly

38. Chest Physiotherapy
▶ Useful in children with segmental or lobar
atelectasis.
▶ In others no therapeutic benefit in the critically ill
patient with status asthmaticus.

39. Summary

40. Thankyou